After the introduction of HAART, the importance of liver-related mortality in HIV–hepatitis C virus (HCV)-coinfected patients has increased substantially. The relative increase in liver-related mortality seen in this population has been due in part to a decrease in 0002030-related mortality associated with the immunological benefits of HAART. In recent cohorts, hepatitis C-related mortality was responsible for up to 11.5% of overall mortality .
Therapy of hepatitis C is a priority in HIV–HCV-coinfected patients. Sustained virological response to anti-HCV treatment can prevent fibrosis progression, decrease end-stage liver disease and increase survival [2,3]. Unfortunately, several studies have demonstrated that only a minority of patients can be appropriately selected for treatment [4,5]. Furthermore, the overall rates of sustained virological response are relatively low in HIV–HCV-coinfected patients [6,7]. Given the current limitations of anti-HCV therapy in patients with HIV–HCV coinfection, it is very important to explore other therapeutic strategies that could delay the progression of hepatic fibrosis.
It has been shown that immunosuppression can increase the rate of liver fibrosis progression in HIV–HCV-coinfected patients . In contrast, several cohorts have suggested that immune recovery after HAART can attenuate liver fibrosis and necroinflammatory activity [9,10]. However, it is not known whether the initiation of HAART above the currently recommended CD4 cell count threshold in antiretroviral-naive patients could be beneficial in HIV–HCV-coinfected patients. Although maintaining a higher count of CD4 cells could slow down liver fibrosis progression, it is also possible that drug-induced steatosis, the immune reconstitution syndrome and drug-related hepatotoxicity secondary to HAART might increase liver damage.
Expert guidelines do not have uniform recommendations about when to start HAART in HIV–HCV-coinfected patients. In the Department of Health and Human Services guidelines, HIV–HCV coinfection is not considered as a category to start HAART at a CD4 cell count above 350 cells/μl . In contrast, European  and International AIDS Society  guidelines consider that the antiretroviral therapy should be considered in HIV–HCV-coinfected patients with CD4 T cell count of more than 350 cells/μl. It is clear that more data are needed to support the decision of an earlier initiation of HAART in HIV–HCV-coinfected patients.
To try to evaluate the impact of HAART in the liver damage of HIV–HCV-coinfected patients with relatively preserved immune status, we performed a detailed study of liver histology of patients who had liver biopsies performed when CD4 cell counts were higher than 350 cells/μl.
Patients and methods
The population for this study was followed at La Paz Hospital HIV clinic in Madrid, Spain. Inclusion criteria were HCV infection diagnosed by a positive serum HCV RNA PCR, negative serum hepatitis B surface antigen and CD4 cell count above 350 cells/μl at the moment of liver biopsy.
Of the 142 patients who met inclusion criteria, 23 were excluded from the analysis because of unknown date of HCV infection (defined as the date of first transfusion or the first year of injecting drug use, n = 13), prior HCV treatment (n = 4), obvious noncompliance with antiretroviral therapy (n = 3), nonassessable liver biopsy sample (n = 2) and unknown HCV genotype (n = 1). The final study population was formed by 119 patients.
The study was approved by the local ethics committee for clinical research. All patients signed written informed consent.
Liver histology evaluation
All liver biopsies were evaluated by a single pathologist who was not aware of the clinical and biological data. Necroinflammatory activity and fibrosis were scored by the Scheuer fibrosis staging system . Steatosis was scored according to the percentage of hepatocytes affected.
We performed multivariate regression analysis to assess the association of the use of HAART at the moment of liver biopsy with the level of liver necroinflammatory activity, defined by Scheuers score of at least 3. As this was a cross-sectional study, we selected necroinflammatory activity as the main variable because using or not using HAART probably has a less time-dependent impact on necroinflammatory activity than on fibrosis progression. We included in the model the following possible confounding independent variables: sex, age, alcohol abuse (daily consumption of any amount of alcohol), HCV genotype (1 or 4 vs. other genotypes), serum HCV RNA levels at liver biopsy (< or >800 000 IU/ml), CD4 cell count at the time of liver biopsy (cells/μl), undetectable HIV viral load (<50 copies/ml), alanine aminotransferase (ALT) levels (IU/l), advanced fibrosis (Scheuer score ≥3) and presence of any grade of steatosis. We also created a qualitative variable to better assess the effect of an increased ALT (ALT >150 IU/l).
For the multivariate model, variables that were associated with necroinflammatory activity in the univariate analysis with a P value of less than 0.1 were included in multivariate models after assessment of multicollinearity. Variables were entered into multivariate models in a forward stepwise fashion.
The statistical analysis was carried out using the SPSS 11.0 software package (SPSS Inc., Chicago, Illinois, USA).
The median [interquartile range (IQR)] age was 38 (35–41) years; 93 patients (78.2%) were men and 29 (24.4%) reported current alcohol abuse. Ninety-three patients (78.2%) were receiving HAART at the time of biopsy. Twenty-six distinct HAART regimens were used, and the median (IQR) of duration of HAART was 206.3 (164.6–273.3) weeks. Of the 26 patients not receiving HAART at the time of biopsy, 19 were antiretroviral naive and seven had interrupted HAART for a median (IQR) of 106.3 (27.1–122.1) weeks before the liver biopsy. Six patients stopped HAART because of structured treatment interruption and one patient because of liver-related toxicity.
Median (IQR) CD4 cell count was 549 (456–675) cells/μl, and 48 patients (40.3%) had plasma HIV-1 RNA load of less than 50 copies/ml. Median (IQR) ALT level at the time of biopsy was 87 (54–131) IU/ml.
Fifty-eight patients (48.7%) had plasma HCV RNA load of more than 800 000 IU/l. HCV genotypes distribution was as follows: genotype 1, 66 patients (55.5%); genotype 2, three patients (2.5%); genotype 3, 31 patients (26.1%) and genotype 4, 22 patients (18.5%).
Twenty-seven patients (22.7%) had advanced liver fibrosis (≥F3). The rest of fibrosis score distribution was: 27 patients (22.7%), F2; 62 patients (52.1%), F1; and three patients, F0. Thirty patients (25.2%) had high liver necroinflammatory activity (Scheuer score ≥3). Two patients had no necroinflammatory activity, 18 patients (15.1%) had a score of 1 and 69 patients (58%) a score of 2. Steatosis (any grade) was present in the liver biopsy of 77 patients (64.7%), and in 22 patients (18.5%) it affected more than 31% of the hepatocytes.
In the univariate analysis, alcohol abuse, serum ALT levels, steatosis and a high fibrosis score were significantly associated with higher necroinflammatory activity. In the multivariate analysis, a high level of ALT, advanced fibrosis and absence of HAART were associated with higher necroinflammatory activity (Table 1).
In our study, we found that the use of HAART appears to significantly decrease liver necroinflammatory activity in HIV–HCV-coinfected patients with CD4 T cell counts higher than 350 cells/μl. The other two factors significantly associated in the multivariate analysis with increased necroinflammatory activity were ALT levels and a higher fibrosis score.
There are several possible explanations for the beneficial effects of HAART on the severity of liver necroinflammatory activity. HAART might be beneficial through the inhibition of HIV replication in the liver. Two recent studies have suggested that HIV can directly cause liver damage [15,16]. In addition, Bräu et al.  have reported that suppression of HIV infection through HAART is associated with a slower HCV-induced liver fibrosis progression rate. Finally, Lin et al.  have shown that exposure to the gp120 protein promoted HCV replication. It is therefore plausible that HAART can decrease liver damage by suppressing HIV replication in the liver. Surprisingly, in our study, suppression of HIV replication in plasma below 50 copies/ml was not associated with a lower level of necroinflammatory activity. As we have evaluated only one viral load at the time of liver biopsy, this result should be taken with caution. It might be possible that maintained viral suppression is in fact associated with lower necroinflammatory activity. Another possible beneficial mechanism of HAART upon liver histology could be by decreasing the level of proinflammatory cytokines in HIV–HCV-coinfected patients .
Our multivariate regression model included several possible confounding variables associated with liver necroinflammatory activity such as steatosis and a higher fibrosis score. Steatosis was not associated with liver necroinflammatory activity in the multivariate model probably because steatosis was also highly associated with advanced fibrosis. It should be noted that because of the strong association between the three histological parameters measured (steatosis, necroinflammatory activity and liver fibrosis), it is difficult to tease out the independent relationships of each of the histological parameter with the use of HAART.
Our study is limited because of its retrospective nature. One important limitation is that we could not have a precise estimate of patient's adherence to HAART. Although we excluded patients with obvious nonadherence from our study, it is possible that the level of adherence might have been variable among the included patients. Ideally, our results should be confirmed by prospective studies that would permit to control variables that are difficult to ascertain in retrospective studies such as adherence and the type of antiretroviral regimen that is associated with less hepatic inflammation.
Other important limitation of our study is the heterogeneous composition of the group of patients off HAART at the time of liver biopsy (antiretroviral naive, structured treatment interruption and treatment interruption due to hepatotoxicity). When we excluded from the analysis the single patient who stopped HAART because of hepatotoxicity, results did not change. If we perform the analysis including only antiretroviral-naive patients, there is still a trend towards an association between lower necroinflammatory activity and the use of HAART at the time of biopsy, although, probably because of the small remaining sample size, statistical significance is lost (P = 0.09). We believe that these sensitivity analyses provide further support to the results of the main analysis.
In summary, these results suggest that HAART might decrease hepatitis C activity in HIV–HCV-coinfected patients with CD4 cell counts of more than 350 cells/μl. Consequently, our study supports the use of HAART in HIV–HCV-coinfected patients to decrease liver damage regardless of CD4 cell counts.
Funding support: FIPSE 36465/03, FIPSE 36443/03 and RD07/0006/2007 (RIS) 569. Dr José F. Pascual Pareja is supported by a grant from the FIS Rio Hortega programme (CM07/00216). Jose R. Arribas is an investigator from the Programa de Intensificación de la Actividad Investigadora en el SNS (I3SNS) 2008, INT07/147.
José F. Pascual Pareja designed the study, conducted the statistical analyses, wrote the original manuscript and addressed the reviewers' comments. Alejandra Caminoa evaluated all liver biopsies. Javier Larrauri was responsible for liver biopsy recruitment and contributed to the interpretation of the results. Juan González-García and Maria L. Montes contributed to the interpretation of the results and revision of the manuscript. Jesús Díez and Marta Grande contributed to the statistical analyses and interpretation of the results. José R. Arribas contributed to the design the study, the interpretation of the results, the writing the original manuscript and the response to the reviewers' comments.
There is no conflict of interest.
Presented in part at the 48th ICAAC; Washington, 25–28 October 2008; abstract #H2319.
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